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| EDITORIAL - COMMENTARY |
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| Year : 2022 | Volume
: 5
| Issue : 2 | Page : 53-55 |
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Pediatric nephrology service in Nepal: Fellows' perspective from training to practice
Ajaya Kumar Dhakal1, Devendra Shrestha1, Vivek Kumar Todi2
1 Department of Paediatrics, KIST Medical College Teaching Hospital, Lalitpur, Nepal
2 Department of Paediatrics, Norvic International Hospital, Thapathali, Kathmandu, Nepal
| Date of Submission | 23-Aug-2022 |
| Date of Decision | 07-Nov-2022 |
| Date of Acceptance | 18-Nov-2022 |
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Ajaya Kumar Dhakal
Department of Paediatrics, KIST Medical College Teaching Hospital, Lalitpur
Nepal
 Source of Support: None, Conflict of Interest: None
A trained workforce in pediatric nephrology subsubspecialty is critical to the prevention, treatment, and reduction of morbidity and mortality associated with kidney disease in the pediatric population. Currently, there is a disparity between the proportion of children with kidney disease and the workforce required to care for these children due to the lack of formal pediatric nephrology training programs in Nepal. As a result, some pediatricians are seeking pediatric nephrology training outside the country with the support of international nephrology or pediatric nephrology associations, whereas others are pursuing training opportunities on their own. This article describes the benefits and shortcomings of such training and the challenges of implementing the skills after returning to a low-resource setting. The article also offers recommendations for further improvements in such fellowship programs.
Keywords: Fellows, Nepal, pediatric nephrology
How to cite this article:
Dhakal AK, Shrestha D, Todi VK. Pediatric nephrology service in Nepal: Fellows' perspective from training to practice. Asian J Pediatr Nephrol 2022;5:53-5 |
How to cite this URL:
Dhakal AK, Shrestha D, Todi VK. Pediatric nephrology service in Nepal: Fellows' perspective from training to practice. Asian J Pediatr Nephrol [serial online] 2022 [cited 2023 Jun 7];5:53-5. Available from: https://www.ajpn-online.org/text.asp?2022/5/2/53/366520 |
| Introduction | |  |
Pediatric nephrology has evolved as a growing subspecialty over the past 50 years, particularly in the middle- and high-income countries. The establishment of the European Society for Pediatric Nephrology in 1967 and the American Society of Pediatric Nephrology in 1969 made it clear that kidney diseases in children are diverse and have distinct epidemiology, pathophysiology, and outcomes that significantly affect kidney health in adulthood.[1] Recent advances in diagnostic molecular genetics, a better understanding of the pathophysiological basis of kidney disease, and clinical studies have greatly improved the outcome of common kidney problems such as nephrotic syndrome, glomerulonephritis, hemolytic uremic syndrome, and pediatric dialysis and transplantation.[1] The widespread availability of prenatal ultrasound services has aided in the early detection of various congenital abnormalities of the kidney and urinary tract. These abnormalities require a specialized postnatal evaluation and complex multidisciplinary treatment. These developments have shaped pediatric nephrology into a unique, dynamic, and progressive field that requires independent subspecialty and specialist training for pediatricians.
The field of nephrology in Nepal, a low- and middle-income country, has developed significantly since the beginning of clinical nephrology services in the early 1980s, hemodialysis service in 1987, and kidney transplantation in 2008.[2] In addition, a 3-year postgraduate program (doctorate in medicine) in adult nephrology started in 2010. Currently, at least 50 nephrologists provide renal services to adult patients.[3] However, pediatric nephrology service in Nepal is still in its infancy compared to the significant stride in services made by developed countries in the past 50 years.[1] The number of personnel trained in pediatric nephrology, with one or more years of training, is far fewer to cope with the increasing burden of pediatric kidney disease in Nepal. Although population-based data are limited in Nepal, hospital-based studies showed that the incidence of pediatric kidney disease among hospital admissions was 11.8%.[4] Similarly, in another study done over 3 years, 8.5% of children presenting with kidney disease in a tertiary care hospital had chronic kidney disease.[5] With such a heavy burden of disease requiring specialized care, Nepal still lacks a training program in pediatric nephrology to provide appropriate health services to this population. This article is a perspective on the authors' experiences attending a pediatric nephrology fellowship program outside of Nepal and transferring the experience, knowledge, and skills back home.
| Training in Pediatric Nephrology | | |
Improved access to health care and the availability of diagnostic services recently revealed a very significant burden of kidney disease in children. In addition, the introduction of government programs for subsidized dialysis and kidney transplant services has increased awareness and health-conscious behavior among parents of at-risk children. These factors probably contributed to the recent surge in pediatric renal patients seeking renal health services.
The shortage and growing demand for trained pediatric nephrology physicians in the country have inspired many pediatricians to pursue this specialization. However, without any formal pediatric nephrology training program in Nepal, prospective fellows must travel abroad to acquire the essential skills and knowledge. Some determined pediatricians seek fellowship opportunities supported by organizations such as the International Society of Nephrology (ISN) and the International Pediatric Nephrology Association (IPNA). In contrast, others have made their own efforts to obtain the training.
Fellowship programs have attracted only keen pediatricians due to the difficulties of traveling and living abroad for a year or more for the training. Challenges include anxiety of leaving home and family behind and the potential, disruption of their professional progress or academic position at their home institution due to absence. Stress can also stem from the differences in language, cultural norms, and etiquette in a foreign country. In addition, staying abroad as part of a fellowship also exacerbates the problem of a low workforce in the home country and the institution.[6] In contrast, adapting to a new environment can also bring excitement and opportunities, such as meeting new people, understanding new health systems, making new acquaintances, future professional networking, and setting up collaborations.
| Skill Translation in the Home Country | | |
Fellows learn and acquire skills in sophisticated diagnostic modalities, treatment options, and equipment/devices that are readily available for patient management in the host country but are often unavailable in the home country. Nonetheless, training and exposure in state-of-the-art medical facilities may help fellows introduce those modalities back home. Another added benefit is continued mentoring after fellowship, where trainees and mentors continue to communicate and work together, first to improve the management of complicated cases, second to collaborate on research projects, and third to support the establishment of newer technologies in the home country. This means that training-initiated opportunities continue even after returning to the home country.[6]
Translating the knowledge and skills of these fellowships to patient management in a low-resource setting has always been challenging. A disadvantage is the country's unique geographical challenges, particularly the Himalayas' rolling mountains and remote locations, which continue to pose problems in accessing primary healthcare services. Other significant issues include the unavailability of advanced diagnostic modalities, the availability and high cost of immunosuppressive medications, challenges in kidney transplants for young children, the high expense or shortage of equipment (e.g., pediatric dialyzers, hemodialysis blood tubing set, and dialysis catheters), and frequent shortages of peritoneal dialysis fluid.[7] Despite these obstacles, the services provided by the authors postfellowship include renal biopsies and dialysis (acute peritoneal dialysis, hemodialysis, and continuous ambulatory peritoneal dialysis) and multidisciplinary collaborations to treat complex pediatric kidney problems. These services have reduced the need for the patient to travel to neighboring countries for treatment and the associated financial burden. To some extent, it has also led to improved follow-up care and the overall quality of medical care. Some patients requiring advanced diagnostic or treatment modalities unavailable in Nepal still go abroad for evaluation. However, once the diagnosis is made, the follow-up is often carried out in the home country.
The authors have used their knowledge, skills, and experience to train teams in various educational institutions. These include a preconference workshop on the management of complex kidney disease, as well as hands-on sessions on kidney biopsies and insertion of rigid peritoneal dialysis catheters at the Nepal Pediatric Society Conference in 2016. Furthermore, the authors were involved in an IPNA teaching course for pediatricians and general practitioners in the Eastern Nepal in cooperation with IPNA in 2017. In addition, an acute kidney injury master class was held in partnership with ISN and the Nepal Pediatric Society in Kathmandu in 2018. Recognizing the importance of regional collaborations in training, one of the authors is affiliated with the Asian Pediatric Nephrology Association as a representative country member. The authors will continue to organize such training programs for general pediatricians.
A gap felt by the authors after the fellowship is the limited research opportunities in the home country. This may be due to a lack of funding, time, and technological limitations despite their interest. State-of-the-art diagnostic modalities and high-precision technology to conduct advanced clinical research are presently unattainable. Nevertheless, the authors have been researching, publishing, or disclosing their findings in different forums.
| The Road Ahead | | |
As we gain more experience, we intend to strengthen and improve the services we provide in our facilities and expand services to areas where pediatric renal care is not currently available. We also want to raise or enhance the standard of our diagnostic and therapeutic modalities to minimize the need to refer patients abroad for advanced services. Pediatric kidney diseases often require a multidisciplinary team approach with specialties such as urology, transplant surgery, genetics, cardiology, radiology, and critical care. The authors are engaging with these specialties to coordinate the care. In the future, our goal is to collaborate with regional and international nephrology and pediatric nephrology societies, primarily to facilitate training, educational programs, research, and specific programs in health promotion and management of kidney diseases. With established collaboration, we intend to develop local protocols and/or adapt regional and international guidelines to tailor to local scenarios. We also recognize the need to explore the application of telemedicine in our settings and “digital mentorship” and social media in the learning of nephrology in this digital era.[8]
In resource-limited settings like ours, where access to essential medical services is limited, ensuring accessibility to sub- and superspecialty services is difficult but not impossible. We recognize the need for teamwork, mentorship, and multidisciplinary collaboration to provide the best possible quality of care to patients with complex renal diseases. Fellowship and academic programs in pediatric nephrology are important options for addressing the acute shortage of specialists in our country. They are also crucial to sustain health systems, improve quality of care and patient compliance, and reduce patient referrals and expenses. Acquiring training abroad has excellent advantages, but comes with some limitations. Therefore, starting a training program in our own country is desirable for a sustainable system. The South Asia health policy documents developed by ISN also suggested focusing on increasing the number of training programs to improve renal services in the region.[3] We remain committed and look forward to establishing formal pediatric nephrology training programs in Nepal in collaboration with national and international institutions. First, a hybrid fellowship model may be suitable. Such a model could include training both in the home and in the host country institutions. Subsequently, hands-on mentorship and short courses by international experts in the home country can be offered regularly. Secondly, training in collaboration with local adult nephrology colleagues may be another short-term solution. We hope to establish such training programs in collaboration with national and international nephrology societies, ultimately leading to improved resources and care for our patients. The authors gratefully acknowledge the continued support they receive from adult nephrologist colleagues, pediatricians, and specialist physicians, as well as the role played by the training institutions and mentors and their continued postfellowship guidance to continue and expand pediatric kidney care despite the challenges.
Author's contribution
AKD, DS, and VKT were involved in writing the original draft and reviewing and editing the manuscript.
Acknowledgment
We would like to acknowledge our mentors; Prof. Rachel Lennon, Paediatric Nephrologist, Royal Manchester Children's Hospital, UK; Prof. Yap Hui Kim, Paediatric Nephrologist, National University Hospital, Singapore; Dr. Kanav Anand, Paediatric Nephrologist, Sir Ganga Ram Hospital, India for continuous support and guiding us.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Shah DS, Shrestha S, Kafle MP. Renal transplantation in Nepal: Beginning of a new era! Nephrology (Carlton) 2013;18:369-75. |
| 3. | Jha V, Ur-Rashid H, Agarwal SK, Akhtar SF, Kafle RK, Sheriff R, et al. The state of nephrology in South Asia. Kidney Int 2019;95:31-7. |
| 4. | Joshi P, Giri BR, Khatun N, Prajapati B, Karki ST. An audit of pediatrics inpatients in general pediatrics department of tertiary care children's hospital. Nepal Med J 2019;2:55-61. |
| 5. | Poudel D, Basnet S, Shrestha L. Clinico-epidemiological profile of children with chronic kidney disease in tertiary care referral center in Nepal: Prospective observational study. Kathmandu Univ Med J 2022;20:198-202. |
| 6. | Harris DC, Dupuis S, Couser WG, Feehally J. Training nephrologists from developing countries: Does it have a positive impact? Kidney Int Suppl 2012;2:275-8. |
| 7. | Basnet N, Adhikari S, Kafle Kumar R. MON-069 Overcoming shortage of peritoneal dialysis solution in Nepal. Kidney Int Rep 2019;4 Suppl 7:S332. |
| 8. | Colbert GB, Topf J, Jhaveri KD, Oates T, Rheault MN, Shah S, et al. The social media revolution in nephrology education. Kidney Int Rep 2018;3:519-29. |
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